Councillor Izzi Seccombe

Izzi first came to county politics in 2001 and has held two portfolio roles. Firstly of children, young people and families from 2005-2010, where she brought together the combined services of education and children’s services and as adult social care portfolio holder between 2010-2013.

Cllr Izzi Seccombe became the first female leader of Warwickshire County Council in May 2013. She has continued to lead her administration with passion, vigour and compassion.

Izzi has been on the LGA community wellbeing portfolio since 2013 and has chaired the board since September 2014.

 

Local government has been actively commissioning services for decades and sees commissioning as a continuous ongoing process, which starts with an assessment of needs, followed by an identification of priorities, market and demand management, contract development and procurement. The NHS sometimes focuses narrowly on procurement, and would benefit from adopting a whole-cycle approach.

Commissioning is far wider than contracting and procurement. Assessing the quality and outcomes of commissioned services is vital to ensure value for public money and to inform future commissioning decisions.

Local government is moving away from commissioning activities or input towards commissioning for outcomes. This approach is person-centred and doesn’t just treat individual health conditions. Its focus is on what matters to the individual: what makes their life worthwhile, and what they want to get out of their life.

Local government is moving away from commissioning activities or input towards commissioning for outcomes. This approach is person-centred and doesn’t just treat individual health conditions. Its focus is on what matters to the individual: what makes their life worthwhile, and what they want to get out of their life.

   

Once this is agreed, a local authority commissions services to support the person to achieve their goals. The NHS still often commissions for a certain number of units of treatment, rather than using a person-centred approach.

Structure and size

One persistent feature of NHS thinking has been to identify a single ‘right-sized unit of planning’, but this doesn’t exist. Let’s accept that some things will be commissioned at specialist/national level, while others will be commissioned at the level of the individual, for example.

Commissioners should be flexible, and understand there isn’t just one level of commissioning. The principle of subsidiarity – taking decisions at the right level, and as near to the user as possible – is vital.

Local government has learned that if you have a fantastic contract specification but it does not accurately address need, then providers’ services won’t always meet those needs or have the right impact.

In my authority, commissioning is the most important thing we do: we can save money and improve services if we get it right. We therefore try to really understand its impact: is it really meeting needs and improving outcomes?

One persistent feature of NHS thinking has been to identify a single ‘right-sized unit of planning’, but this doesn’t exist. Let’s accept that some things will be commissioned at specialist/national level, while others will be commissioned at the level of the individual, for example.

   

Focus on the individual’s wants and needs

Integration is not an end in itself: it is a means of shaping the whole commissioning cycle around individuals’ needs. Local government has a longer track record of personalisation, choice and control, but, increasingly, we need to work together across organisational boundaries to ensure that services are effective in improving outcomes.

Personalising services to the needs of users and future users means really understanding what support they need to live their lives to the best of their ability. This makes co-production hugely important to successful commissioning.

A level, diverse playing field of provision

Maintaining diversity and choice in the residential  and domiciliary care provider markets has been hard in times of austerity. Experience has shown that provider market diversity is very important. In adult social care, an increasing number of providers are leaving the market because they no longer see a viable business.

But it is not just about domiciliary support and residential care.

Adult social care is leading a shift to more person-centred, preventive models. Small, locally-rooted community or voluntary sector groups are often most likely to maximise their impact for clients’ independence, and so provide the most effective services. Heavy-handed or unduly rigorous procurement risks being unfair to these groups. It’s important to find a way to level the playing field for those organisations.

Dealing with complexity

Aiming to commission for outcomes rather than activity is challenging for local authority commissioners and their providers, especially when commissioning across more complex care pathways with many providers involved. How providers and contract managers understand this complexity is important. The Commissioning for Better Outcomes Framework developed by the Association of Directors of Adult Social Care, the Department of Health, Think Local Act Personal, ADASS and the Local Government Association raise some of these issues.

Commissioning for outcomes along complex pathways poses a particular challenge for the NHS, as the vast majority of money passes through tariffs based on activity and not outcomes (and unbundling tariffs can be difficult).

Rebalancing the power dynamic between commissioners and providers.

We need to develop a ‘parity of esteem’ between commissioners and providers but this can be difficult because of the imbalance of power and resources, most of which are held by large acute trusts. Commissioners’ challenge is that NHS providers, especially big providers, don’t necessarily look to a locality base as their patient flow – and income – comes from far further afield.

We need to develop a ‘parity of esteem’ between commissioners and providers but this can be difficult because of the imbalance of power and resources, most of which are held by large acute trusts. Commissioners’ challenge is that NHS providers, especially big providers, don’t necessarily look to a locality base as their patient flow – and income – comes from far further afield.

   

Successful commissioning needs an equal conversation between commissioners and providers. In the NHS, that relationship needs rebalancing.

Sustainability and transformation partnerships

Sustainability and transformation partnerships (STPs) are beginning to embed themselves within local health and care systems as the primary unit of planning for health – and to a lesser extent care – encompassing both providers and commissioners.

STP footprints are clearly in the business of managing significant change and redesign of local systems, affecting many organisations. STP processes should ideally help align commissioner and provider plans across these larger footprints, commissioning the right services at the right level.

But STPs need to be an inclusive partnership to improve population health and services.  If they are not, then the chances of them achieving their objectives are slim.  The lack of involvement of elected members and communities via health and wellbeing boards is an obvious concern for the LGA. We need urgent action to remedy this, as STPs move towards delivery and implementation.

There is real potential for STPs to reshape services for the benefit of their local communities, but they need to be genuine partnerships between health, local government and the community and voluntary sector. The LGA urges senior leaders to be involved and influence local conversations.

There is real potential for STPs to reshape services for the benefit of their local communities, but they need to be genuine partnerships between health, local government and the community and voluntary sector. The LGA urges senior leaders to be involved and influence local conversations.

   

Working with clinical commissioning groups, and local-vs-national tensions

We have a national health service and national inspection and monitoring, but local government and local clinical commissioning groups (CCGs). How does the national framework support local provision and place-based approaches?

While CCGs are relatively new organisations with huge challenges, one very positive aspect is that they are clinically-led. In most places, any concerns about CCGs from local government about how new GP-led bodies might relate to and work with partners in local government, have been dispelled by experience of working together.

In practice, we found we shared many values. CCG commissioners have a clear sense of place, and of the patient as a whole person with assets beyond their health challenges. In the main, local government has worked well with CCGs that have worked hard to move beyond thinking in very health-centric, internally-focused terms of NHS services, and reflected on how best to work with local government. They have developed and matured significantly in just a few years, as have health and wellbeing boards. Any reshaping of health systems, such as developing accountable care systems must build on the partnership working between health and local government, rather than undermining it.

Local-versus-national tensions do not only affect CCGs: the entire NHS gets pulled in two different directions. Acute contracts are mostly left with the CCG, who work with local government partners on place-based approaches, while also working to national frameworks and performance targets. That is uncomfortable and makes it very hard to satisfy both constituencies.

While CCGs are relatively new organisations with huge challenges, one very positive aspect is that they are clinically-led. In most places, any concerns about CCGs from local government about how new GP-led bodies might relate to and work with partners in local government, have been dispelled by experience of working together.

   

Commissioner-provider split

Local government’s clear distinction between commissioning and provision means we do not necessarily see it as an insuperable conflict of interest if both functions are located in one organisation.

That requires a level of independence and challenge if commissioners are providing services, so there is a level playing field for in-house and other providers, to secure best value for money and best outcomes.

If no providers are involved in your commissioning planning, you may not understand the whole picture of their potential impact, and what you might need.

We can get very precious about who sits at the table on conflict of interest grounds, but all participants must focus on what they’re trying to achieve together. It is public money, so we have to show that decisions are reached in a fair, proper and value-for-money way.

The purchaser-provider split is an evolving, non-static situation. As with the NHS, local government is a world of continual change. There will be movement around where the payer-provider split happens. I hope we deliver integration and deliver around commissioning for the future.

Useful learning

Ultimately, there is useful learning for the NHS from local government’s approach to commissioning. It is about so much more than contracting and purchasing and, when seen in this light, the role and value of commissioning can be truly appreciated.